Reply
Authors: Nawras Habash, Imad Abash
Journal: Clinical Gastroenterology and Hepatology (2023)

We appreciate the interest shown by Karime et al. in our study.1Ulrich J.A. et al.Clin Gastroenterol Hepatol. 2023; 21: 2901-2907.e2Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar We would like to express our gratitude for their insightful remarks. In response to their letter, we would like to address the raised points and provide a comprehensive response. The recent recommendations from the Centers for Disease Control and Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP) regarding hepatitis B (Hep B) virus screening and vaccination aim to improve population screening and enhance vaccination coverage. These recommendations were made in response to low vaccination rates in patients age 19 years and older, which led to a subsequent increase in the incidence of acute Hep B infection, particularly in adults between the ages of 30 and 49 years, accounting for approximately half of the acute Hep B infections in 2019.2Universal hepatitis B vaccination in adults aged 19–59 years: Updated recommendations of the Advisory Committee on Immunization Practices - United States. Centers for Disease Control and Prevention, 2022https://www.cdc.gov/mmwr/volumes/71/wr/mm7113a1.htmDate accessed: June 30, 2023Google Scholar,3Screening and testing for hepatitis B virus infection: CDC recommendations - United States. Centers for Disease Control and Prevention, 2023https://www.cdc.gov/mmwr/volumes/72/rr/rr7201a1.htmDate accessed: June 30, 2023Google Scholar However, there has been a decrease in cases of acute Hep B infection among patients age 19 years and younger since 2005, with no reported cases since 2011.3Screening and testing for hepatitis B virus infection: CDC recommendations - United States. Centers for Disease Control and Prevention, 2023https://www.cdc.gov/mmwr/volumes/72/rr/rr7201a1.htmDate accessed: June 30, 2023Google Scholar These findings were reflected in the guidelines that exempted patients younger than age 18 years from the universal Hep B screening and vaccination policy.3Screening and testing for hepatitis B virus infection: CDC recommendations - United States. Centers for Disease Control and Prevention, 2023https://www.cdc.gov/mmwr/volumes/72/rr/rr7201a1.htmDate accessed: June 30, 2023Google Scholar The lower rate of infection in this patient population highlights the effectiveness of the Hep B vaccination when patients receive the full series. Our study's findings align with the recommendations and findings of the CDC and ACIP.1Ulrich J.A. et al.Clin Gastroenterol Hepatol. 2023; 21: 2901-2907.e2Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar,4Habash N. et al.J Pediatr Gastroenterol Nutr. 2022; 74: 328-332Crossref PubMed Scopus (6) Google Scholar Specifically, we found no increased risk of Hep B infection in patients who completed the full series of the Hep B vaccine, suggesting that screening for immunity in patients who received the full vaccine series may not be necessary. Nonetheless, screening for dormant infection should always be completed. An important point raised in the ACIP and CDC guidelines is that vaccinating individuals before the onset of conditions known to affect the response to the Hep B vaccine improve long-term protection.2Universal hepatitis B vaccination in adults aged 19–59 years: Updated recommendations of the Advisory Committee on Immunization Practices - United States. Centers for Disease Control and Prevention, 2022https://www.cdc.gov/mmwr/volumes/71/wr/mm7113a1.htmDate accessed: June 30, 2023Google Scholar,3Screening and testing for hepatitis B virus infection: CDC recommendations - United States. Centers for Disease Control and Prevention, 2023https://www.cdc.gov/mmwr/volumes/72/rr/rr7201a1.htmDate accessed: June 30, 2023Google Scholar This point deserves attention because the universal vaccination program in childhood currently provides individuals with the vaccine before the age of 12 to 18 months, typically during the first 6 months of life, when patients do not have celiac disease or inflammatory bowel disease. Furthermore, according to the ACIP guidelines, individuals who have completed a Hep B vaccination series at any point or who have a history of Hep B infection should not receive additional Hep B vaccination. This aligns with their previous statement that the best evidence of immunity is a history of receiving the full vaccine series.2Universal hepatitis B vaccination in adults aged 19–59 years: Updated recommendations of the Advisory Committee on Immunization Practices - United States. Centers for Disease Control and Prevention, 2022https://www.cdc.gov/mmwr/volumes/71/wr/mm7113a1.htmDate accessed: June 30, 2023Google Scholar As noted by the CDC guidelines, universal screening policies are not without risks, which raised valid points regarding potential harms such as stigma, fear, distress associated with false-positive results, and health care–related costs, including insurability.3Screening and testing for hepatitis B virus infection: CDC recommendations - United States. Centers for Disease Control and Prevention, 2023https://www.cdc.gov/mmwr/volumes/72/rr/rr7201a1.htmDate accessed: June 30, 2023Google Scholar Karime et al commented on the lower response rate in patients with inflammatory bowel disease to the Hep B vaccination. It is worth noting that measuring Hep B surface antibody titers is currently the predominant method for evaluating vaccine immunity. Those titers naturally decrease over time, which does not necessarily equate to lack of immunity. Studies have emphasized the significance of immune memory and cellular immunity in vaccine-induced immunity. Individuals who have received vaccination against a specific pathogen can mount a rapid protective response through immune memory, providing adequate protection when the incubation period allows for the development of a new immune response.5Simons B.C. et al.J Infect Dis. 2016; 214: 273-280Crossref PubMed Scopus (61) Google Scholar,6Pollard A.J. et al.Nat Rev Immunol. 2021; 21: 83-100Crossref PubMed Scopus (656) Google Scholar A recent review article in Nature Reviews Immunology by Pollard and Bijker6Pollard A.J. et al.Nat Rev Immunol. 2021; 21: 83-100Crossref PubMed Scopus (656) Google Scholar further underscores this issue, using Hep B virus as an illustrative case study. The investigators emphasized that the extended incubation period of Hep B virus, ranging from 6 weeks to 6 months, allows the body sufficient time to generate the required protective antibodies. This suggests that revaccination may not be necessary for individuals with low antibody titers. This viewpoint has been adopted by the ACIP, which recommends that documented completion of the primary vaccine series serves as more robust evidence of immunity than a protective titer for the Hep B surface antibodies. Regarding the generalizability of our study findings, we acknowledged the limitation of our study's patient population. Further studies that include a more diverse patient population and populations in whom Hep B infection is more endemic would provide valuable insights for shaping future recommendations. Further research is essential to comprehensively understand the role of routine Hep B immunity screening, the impact of revaccination in immunocompromised populations, and the potential integration of the incubation period of specific pathogens into vaccine strategy planning. Measuring of Postvaccination Hepatitis B Titers in Patients With Inflammatory Bowel Disease: Thoughts for Further InvestigationClinical Gastroenterology and HepatologyVol. 22Issue 1PreviewWe read with interest the study by Ulrich et al1 titled "Effectiveness of Hepatitis B Vaccination for Patients with Inflammatory Bowel and Celiac Disease." In this study, Ulrich et al1 retrospectively investigated the effectiveness of hepatitis B virus (HBV) vaccination in patients with inflammatory bowel disease (IBD) or celiac disease in Olmsted County between 2000 and 2019. They identified 351 patients who received 2 or more HBV vaccines and subsequently underwent anti-HBV titer measurement at a median of 13.2 months. Full-Text PDF